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Examining the future of healthcare

29 Sep 2016

Donal Duffy, IHCA Assistant Secretary General — ‘15 years ago I had another ‘Hallelujah’ moment’

With the Oireachtas Committee on the Future of Healthcare now sitting, IHCA Assistant Secretary General Donal Duffy warns that failure to learn from the past may only lead us to repeat the very same mistakes

Hallelujah, the future of the health service is secure.

The Dáil recently formed a special all-party Committee to ‘devise cross-party agreement on a single long-term vision for health care and direction of health policy in Ireland’.

Amongst its tasks are the following:
• the Committee shall examine existing and forecast demand on health services, including the changing demographics in the Irish population;
• the Committee shall examine and recommend how to progress a changed model of healthcare that advocates the principles of prevention and early intervention, self-management and primary care services as well as integrated care;
• the Committee shall examine different funding models for the health service and make recommendations on the funding models that are best suited to Ireland and have these models fully costed;
• the Committee shall examine and make recommendations on how best to reorientate the health service on a phased basis towards integrated, primary and community care, consistent with highest quality of patient safety, in as short a time-frame as possible.

A useful first exercise for any Committee examining the Irish healthcare system is to identify the root causes of the current service’s failure to provide the type of care that a modern day Republic should have available to its people. Failure to learn from the past may only lead us to repeat the mistakes of the past.

Fifteen years ago we had another Hallelujah moment when Quality and Fairness a Health System for You was published by the Department of Health and Children and endorsed by the Government. This was supported by a number of other reports, including Acute Hospital Bed Capacity, A National Review.

That Strategy contained 121 actions to be undertaken. The responsibility for implementing each one was clearly identified. It is informative to review some of them in the context of the new Committee’s terms of reference.

Forecast demand

The Bed Capacity Report identified the demand for hospital beds up to 2011. It concluded that an additional 2,840 inpatient beds and 190 day care beds would be required. History and waiting lists will show that the requirements identified were not delivered.

The current budgeting system for the health service does not attempt to forecast demand for services. Instead, it examines what has been done in previous years and seeks to match that with some incremental improvement lollipops added periodically.

It is useful that the Committee will examine existing and forecast demand for the health service. Why has this not been done routinely every year? Is that not a significant governance failure from the very top?

The CSO has been publishing population projections for years. It should not come as a great shock to the Committee that the population over the age of 65 is growing and will continue to grow rapidly for years to come. It is from that cohort the majority of patient needs for services derive.

Changed model
I had a sense of déjà vu when I read this. Objective two of the 2001 Health Strategy deals with the ‘intensification of the promotion of health and wellbeing’.

Actions on smoking, alcohol and diet and exercise were identified. These included various initiatives to address these major risk factors. Programmes were also advocated that would lead to a reduction in health inequalities.

The Strategy advocated an enhanced model for primary care, overseen by a National Task Force. By 2011 we were to have 400 – 600 primary care teams and networks in place.

Funding

The Strategy had eight separate actions on funding. One potential model, health insurance, was swiftly rejected by the Department in advance of the Strategy. The reason posited by the Department representative on the relevant committee was that hospitals would be operating out of the control of the Department. I was not surprised when former Minister James Reilly’s proposals for just such a scheme did not advance as speedily as he may have wished.

Reorientation

I am finding it difficult to understand the difference between the second and fourth objective above. Both appear to want to drive more care through primary care. Why has this not happened over the past 15 years? Circa 95 per cent of healthcare is delivered through primary care as it is. Is it that the scope for delivering much greater care through primary care is simply not there?

There has not been any evidential basis produced to support the reorientation as described above. We are living in an age where there ought to be greater openness and transparency.

It is incumbent on our legislators to set out the rationale for further re-orientation and to clarify what is to become of those patients for whom primary care alone is not the answer.

Conclusion
Much of what the Committee is about was already done 15 years ago. A more useful role for our parliamentarians would be to reflect, in the first instance, on why the various recommendations made and supported by Government have not been implemented over a decade and a half. That is not to say that a review is not timely. The shelf life of that strategy is long since passed.

As I write this, the Minister for Health is quoted as saying it was up to clinicians to make decisions for the health services and not politicians. I couldn’t have put it better myself.

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Click here to view the full article which appeared in Irish Medical Times: Opinion